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Priority Setting: Priority Setting: Beyond Evidence-based Beyond Evidence-based
Medicine and Cost-Medicine and Cost-effectiveness Analysis effectiveness Analysis
Priority Setting: Priority Setting: Beyond Evidence-based Beyond Evidence-based
Medicine and Cost-Medicine and Cost-effectiveness Analysis effectiveness Analysis
Douglas K. Martin, PhDDouglas K. Martin, PhDDirector, Collaborative Program in Bioethics,Director, Collaborative Program in Bioethics,
Assistant Professor, Department of Health Policy, Management and Evaluation, Assistant Professor, Department of Health Policy, Management and Evaluation, and the Joint Centre for Bioethics, University of Torontoand the Joint Centre for Bioethics, University of Toronto
Career Scientist, Ontario Ministry of Health and Long-Term CareCareer Scientist, Ontario Ministry of Health and Long-Term Care
OutlineOutline
Where we have been – the 1980s & Where we have been – the 1980s & 1990s1990s
Where we are going – 2000 to 2010Where we are going – 2000 to 2010 Improving priority setting Improving priority setting
PS: Distribution of goods and services PS: Distribution of goods and services among competing needsamong competing needs
PS occurs at all levels of systemPS occurs at all levels of systemgovernment, RHAs, disease management government, RHAs, disease management
organizations, research agencies, PBM, organizations, research agencies, PBM, hospitals, clinical programshospitals, clinical programs
rationing rationing resource allocation resource allocation
priority setting priority setting
sustainabilitysustainability
Where we have beenWhere we have been
Evidence-based Medicine & Evidence-based Medicine & Cost-effectiveness AnalysisCost-effectiveness Analysis
Dominant tradition; Dominant tradition; HTA = TAHHTA = TAH Technical problemsTechnical problems
– Levels of evidence; types of benefits; availabilityLevels of evidence; types of benefits; availability– WB “The Economics of Priority Setting for Health WB “The Economics of Priority Setting for Health
Care” (2003): problems with economic evaluations; Care” (2003): problems with economic evaluations; incorporating equity; practical constraintsincorporating equity; practical constraints
PaussJensen, Singer, Detsky. Ontario’s PaussJensen, Singer, Detsky. Ontario’s Formulary Committee How Recommendations Formulary Committee How Recommendations are Made. are Made. PharmacoeconomicsPharmacoeconomics (2003). (2003). – ““Complex economic analyses played a limited role.”Complex economic analyses played a limited role.”
Helpful but limited; necessary but not sufficientHelpful but limited; necessary but not sufficient
Let’s be clear: PS decisions Let’s be clear: PS decisions are . . . are . . .
NOT information-based decisionsVALUE-BASED DECISIONS
AND THESE VALUES OFTEN CONFLICT
Evidence
Benefit
Risk Equity
Equality
Access
Rule-of-Rescue
Efficiency
Individual ResponsibilityNeed
Solidarity
Compassion for the Vulnerable
Democratic deliberation
Martin, Singer 2000Martin, Singer 2000
Gaps in knowledgeGaps in knowledge
Goodbye to simple solutions Goodbye to simple solutions (Holm, BMJ 2000)(Holm, BMJ 2000)
Normative approaches Normative approaches (e.g. philosophy, health (e.g. philosophy, health economics)economics)
help identify values help identify values but conflict, no consensus, too abstractbut conflict, no consensus, too abstract
Empirical approachesEmpirical approaches what is done \ what can be donewhat is done \ what can be done but not what should be done but not what should be done
International experience shows difficulty International experience shows difficulty reaching agreement on reaching agreement on whatwhat decision decision should be made should be made (Ham, Coulter, JHSRP 2001) (Ham, Coulter, JHSRP 2001)
Can agree on Can agree on howhow : Fair process: Fair process
But, But,
what is what is fairfair??
Daniels & Sabin, 1997Daniels & Sabin, 1997
‘‘Accountability for Accountability for reasonableness’reasonableness’
RelevanceRelevance: : based on based on reasonsreasons upon which stakeholders can upon which stakeholders can agree in the agree in the circumstancescircumstances
PublicityPublicity: : reasonsreasons publicly publicly accessibleaccessible
Revision/AppealsRevision/Appeals: : mechanism for mechanism for challenging/revising challenging/revising reasonsreasons
EnforcementEnforcement: : to ensure 3 to ensure 3 conditions metconditions met
Martin, Singer, 2000Martin, Singer, 2000
Where we are goingWhere we are going ““Simple solutions” on one hand Simple solutions” on one hand
and “muddling through” on the and “muddling through” on the other, or substantive versus other, or substantive versus procedural criteria, represent procedural criteria, represent dialectically opposite dialectically opposite extremes. A synthesized extremes. A synthesized conceptual model or conceptual model or framework, grounded in real framework, grounded in real experience and taking account experience and taking account of various discipline-specific of various discipline-specific perspectives, represents perspectives, represents the next phase of priority the next phase of priority setting.setting.
Gibson, Martin, Singer. BMCHS, 20Gibson, Martin, Singer. BMCHS, 200404
Criteria & Process: Criteria & Process: Parameters of SuccessParameters of Success
Competing goals and multiple stakeholder Competing goals and multiple stakeholder relationshipsrelationships
Efficiency considerations or technical solutions Efficiency considerations or technical solutions limited influence, not sufficient limited influence, not sufficient
An evaluation of the normative 'rightness' [of An evaluation of the normative 'rightness' [of ps criteria] depends on the specific ps criteria] depends on the specific institutional circumstances, the stakeholders institutional circumstances, the stakeholders who are affected, and the strategic goals that who are affected, and the strategic goals that are being pursued.are being pursued.
Underscores the importance of procedural Underscores the importance of procedural fairness to secure socially acceptable priority fairness to secure socially acceptable priority setting decisions and to ensure public setting decisions and to ensure public accountability.accountability.
Informal Networks of Informal Networks of DeliberationDeliberation
Beyond formal institutional structuresBeyond formal institutional structures Emphasizes ‘public good’ over ‘private Emphasizes ‘public good’ over ‘private
interests’interests’ Context where claims must be justified; Context where claims must be justified;
actions shaped by requirements of actions shaped by requirements of justification justification [Chaves, 1974][Chaves, 1974]
Provides more information about Provides more information about others’ preferences others’ preferences
Engages inherent human ability to Engages inherent human ability to assess different reasons assess different reasons [[ManinManin, 1987], 1987]
Renders decision legitimate in the Renders decision legitimate in the eyes of participants; eyes of participants;
Groups can pool their experience Groups can pool their experience and creativity and creativity
Enhances ‘buy-in’ Enhances ‘buy-in’
Martin, Singer, Health Care AnalysiMartin, Singer, Health Care Analysis 2003s 2003
Improving Priority SettingImproving Priority Setting DescribeDescribe
Case study methodsCase study methodsWhat groups actually doWhat groups actually do
EvaluateEvaluate ‘‘Accountability for reasonableness’Accountability for reasonableness’ What groups should doWhat groups should do Correspondence: good practicesCorrespondence: good practices Gaps: opportunities for Gaps: opportunities for
improvementimprovement
ImproveImprove Implement strategies to close gapsImplement strategies to close gaps
Benefits of Benefits of describe/evaluate/improvedescribe/evaluate/improve
Institution:Institution: quality improvementquality improvement political involvement political involvement learning organizationlearning organization leadershipleadership
Other health care organizationsOther health care organizations: : share good practicesshare good practices
Martin, Shulman, Santiago-Sorrel, SMartin, Shulman, Santiago-Sorrel, Singer, JHSRP 2003inger, JHSRP 2003
Example #1: Example #1: PS and Hospital Strategic PlanningPS and Hospital Strategic Planning
Relevance Relevance ensure info captures impact on academic ensure info captures impact on academic
programs and hospital’s communityprograms and hospital’s community optimize inclusivity / exclusivityoptimize inclusivity / exclusivity revise agreement mechanismrevise agreement mechanism
PublicityPublicity comprehensive communication plancomprehensive communication plan clarify op and strategic planclarify op and strategic plan
AppealsAppeals develop appeals grounds / processdevelop appeals grounds / process
EnforcementEnforcementstart data consultation & data collection start data consultation & data collection
earlierearlierdescribe, evaluate, and improve again!describe, evaluate, and improve again!
Other examplesOther examples Health SystemHealth System
Martin, Singer “Canada” in Ham & Roberts (eds) Martin, Singer “Canada” in Ham & Roberts (eds) Reasonable Rationing.Reasonable Rationing. 2003 2003
Provincial Drug Formulary Provincial Drug Formulary PaussJensen, Detsky, Singer PaussJensen, Detsky, Singer Pharmacoeconomics Pharmacoeconomics 20022002
Hospital Drug FormularyHospital Drug Formulary Martin, Hollenberg, MacRae, Madden, Singer Martin, Hollenberg, MacRae, Madden, Singer Health Health
Policy 2003Policy 2003 Cancer DrugsCancer Drugs
Martin, Pater, Singer Martin, Pater, Singer LancetLancet 2001 2001 ICUICU
Mielke, Martin, Singer Mielke, Martin, Singer Critical Care Medicine Critical Care Medicine 20032003 Martin, Bernstein, Singer Martin, Bernstein, Singer J Neur, Neurosurg, Psych J Neur, Neurosurg, Psych 20032003
Database of LearningDatabase of LearningRelevanceRelevance PublicityPublicity AppealAppeal
ssEnforceEnforce
Health systemHealth system
MoHMoH
PBMPBM
Disease Manag. Disease Manag. OrgsOrgs
RHAsRHAs
Hosp Strat PlanHosp Strat Plan
Hosp Oper PlanHosp Oper Plan
Hosp drug Hosp drug formularyformulary
Clinical Clinical ProgramsPrograms
Social Policy LearningSocial Policy Learning
Make ‘private’ decisions Make ‘private’ decisions publicpublic
Educative functionEducative function Body of ‘case law’; Body of ‘case law’;
institutional reflective institutional reflective equilibriumequilibrium
Iterative - improves Iterative - improves over timeover time
Priority
Setting
Beyond and ForwardBeyond and Forward Synthesis: Criteria & ProcessSynthesis: Criteria & Process
– Value-based decisions about which Value-based decisions about which there is much conflictthere is much conflict
– EBM & CEA necessary but insufficientEBM & CEA necessary but insufficient– Fair process enhances legitimacy & Fair process enhances legitimacy &
accountabilityaccountability Informal networks of deliberationInformal networks of deliberation
– creates climate of ‘public good’, creates climate of ‘public good’, assessment of reasons; enhanced assessment of reasons; enhanced problem-solving; increased ‘buy-in’problem-solving; increased ‘buy-in’
Describe-evaluate-improve approachDescribe-evaluate-improve approach Ongoing process of social policy Ongoing process of social policy
learninglearning
AcknowledgementsAcknowledgements The JCB PS Research Team:The JCB PS Research Team:
Mark Bernstein, Scott Berry, Jennifer Mark Bernstein, Scott Berry, Jennifer Gibson, Heather Gordon, Lydia Gibson, Heather Gordon, Lydia Kapiriri, Shannon Madden, David Kapiriri, Shannon Madden, David Reeleder, Zahava Rosenberg-Reeleder, Zahava Rosenberg-Yunger, Peter A. Singer, Ross Yunger, Peter A. Singer, Ross Upshur, Nancy WaltonUpshur, Nancy Walton
Norman Daniels has contributed Norman Daniels has contributed enormously to our understandingenormously to our understanding
www.canadianprioritysettingwww.canadianprioritysetting.ca.ca
Funded by grants from CIHR